4. Paradigm Shift
Edward Deming, Shigeo Shingo and others perfected the
the Toyota production System(TPS) by bringing Statistical
Process Control and quality to Japan. Lean as we know it
today was born.
We would like to introduce another concept, Patient
Activation Measure(PAM).
What lean was to the TPS, PAM would be to population
management. With Lean already engraved in our DNA
reduction of Total Cost of Care (TCOC) with PHM will be
possible.
Power Point Template 3 4
6. Failed Strategies
Neither financial Incentives nor information strategies
have proven to have sufficient power to change and
sustain consumer behavior.
Chronic care models/medical homes emphasize patient-
oriented care yet have had difficulty showing success in
return on investment.
Self management support programs have shown little
improvement in clinical outcomes for those with chronic
illnesses.
Trying to find a predictive model to identify
patients/consumers before they become high utilizers has
been unsuccessful except for AIM, Palliative and Hospice
care
Power Point Template 3 6
7. Paradigm shift
Points we will discuss today.
How do you measure behavior and effect a change.
PAM-Science behind the modality
Using systematic measurement to target consumer
activation strategies.
The concept of “activation” as an organizing construct to
increase consumer involvement in health.
Illustrative data that show how activation levels are
associated with engaging in specific health behaviors.
The strategy of measuring activation and calibrating both
the type and the amount of support for consumers is
discussed as a way to improve current approaches.
7
8. Paradigm Shift
Tailoring activation to the individual, group, and
community level.
Behaviors that are more challenging for consumers are
unlikely to be adopted among those who are less
activated.
Encouraging behaviors that are more realistic for the
individual given the level of activation can improve the
efficacy of current efforts.
Power Point Template 3 8
10. Background on PAM
PAM went through various development stages.
Defining the construct;
Development and psychometric testing, including
reliability and validity testing;
Determining whether the construct is changeable;
Determining whether tailoring activation to specific levels
improve outcomes
Psychometric analysis was conducted using Rasch
stochastic measurement models and methods
(Andrich,1978; Wright & Masters, 1982; Wright & Stone,
1979), as well as selected classical test theory (CTT) and
item response theory (IRT) statistics.
Power Point Template 3 10
11. • 13-question
• Based on responses to the survey, each person is
assigned
–Activation Score
–Level
PAM
12. Patient Activation Measure (PAM) Items
When all is said and done, I am the person who is responsible for taking care of my
health problems.
Taking an active role in my own health care is the most important thing that affects my
health.
I am confident I can help prevent or reduce the problems associated with my health
condition.
I know what each of my prescribed medications do.
I am confident I can tell whether I need to go to the doctor or whether I can take care of
a health problem myself.
I am confident that I can tell a doctor my concerns, even when he or she does not ask.
I am confident I can follow through on medical treatments I need to do at home.
I understand my health problems and what causes them.
I know what treatments are available for my health problems.
I have been able to maintain (keep up with) lifestyle changes, like eating right or
exercising.
I know how to prevent further problems with my health condition.
I am confident I can figure out solutions when new problems arise with my health
condition
I am confident I can maintain lifestyle changes, like eating right and exercising, even
during times of stress.
Power Point Template 3 12
13. Level 1 : May not yet believe that the patient role is
important
– PAM Score of 47.0 or lower
Level 2: Lacks confidence and knowledge to take action
– PAM Score of 47.1 to 55.1
Level 3: Beginning to take action
– PAM Score of 55.2 to 67.0
Level 4: Has difficulty maintaining behavior over time
– PAM Score of 67.1 or above
Meaning of #s
Better
as
score
rises
18. Increasing Activation at Group Level
Delivery system could stratify their enrolled patient
population by both clinical indicators [example blood
pressure or cholesterol levels]as well as their activation
level.
This allows for early intervention with patients who have
clinical risk factors and who lacks skills to self manage
[that is level1 or level 2].
This allows limited resources to be used efficiently.
When employed throughout the organization economy of
scale would show real reduction in TCOC.
Power Point Template 3 18
21. Impact effort Matrix
Power Point Template 3 21
High Impact High Impact
low effort High effort
Low Impact Low impact
Low effort High Effort
22. Greatest ROI
Power Point Template 3 22
Hospital
admit
ER
PAM
SCC
OB/GYN
Peds
F.P
PAM
Internal
Med.
PAM
Ancillary
Services
PAM
Urgent
Care
PAM
SNF
PAM
23. Cost Avoidance
Power Point Template 3 23
67 68
78
118
87
0
50
100
150
200
250
300
350
400
450
500
$-
$100,000
$200,000
$300,000
$400,000
$500,000
$600,000
Jan Feb Mar Apr May
Sutter Compass Connect Cost Avoidance
(2015)
# of urgent visits to SCC
Direct Cost ($1861/day)
Total Cost ($3,485/day)
Assumptions:
• 17% of patients are admitted from ED
• Avg Direct Cost of ED visit = $515/visit
• Avg Total Cost of ED visit = $911/visit
• Avg Direct Cost per patient = $1,861/day
• Avg Total Cost per patient = $3,485/day
• Medicare ALOS = 5.72
YTD Direct Cost Avoidance: $941,030
YTD Total Cost Avoidance: $1,743,719
Editor's Notes
We have the best doctors and staff. Eg Kevin, Dave, Jjean , Dr. Ahmed.
We might be victims off our own success. Attracting the sicker population.
Strong and bold statement. We would not have landed man on the moon if we were squimish.
Access to health care. Or genetics ,Environment or perhaps behaviour. Since behavior is the key to our health status how do we change behaviour.
Lots of things have
when data fits into the Rasch measurement model it is not only reproducible but it captures the construct from the patients perspective rather than the researchers. Pam has demonstrated strong validity for self management behaviors, self rated health status and a measure of health fatalism.
So how do these scores correlate with disease conditions and their management by the patient? And whether it is changeable? Studies have shown that when activation changes so does the health of the patient.
When we taylor chronic disease management according to the PAM level greater success is achieved. E.g I just saw a patient referred by an outside PCP. She had DM and newly diagnosed breast cancer. Pcp implemented state of art treatment for dM but could not budge HGBA1c from 8.5. patient’s PAM was level 1.
Engagement of the patient corresponds to activation level. Level four read complications, bring doctor a list of problems, persistence in asking
Again we see the same pattern for health behaviors.
this slide again shows the same story. We
We can not only move patient up the activation ladder, but we can also tailor our resources more appropriately and perhaps graduate patient from SCC once patient s are at level 4.
Greatest impact would be in the hospital to get quickest ROI. Behavior here is not only the patients but the doctors taking care of patients. very important. E.g. hand washing project at Lodi memorial hospital. Reduce the risk of hospital induced disability by minimizing restricted diet,, bed rest ordersto be avoided with recommendations that patient ambulate 3-4 times a day and be out of bed and in chair for all meals.Totally avoid indwelling catheters,IV poles, nasal cannulas, pulse oximetry and telemetry. Inouye et all 1999 early ambulation and active range of motion exercises for bed bound patients reduces Delirium. 30 % all hospitalized patients and 50% post op patient. Upon discharge PAM will show where to concentrate resources. We need healthier population to offset our sicker patients. Open internal medicine patient s to all insurances. We are all in it together. I would request the specialist to ask the hospitalist what can we do to help discharge patient appropriately.
